The Social Determinants of Health in India

The Social Determinants of Health in India. Devaki Nambiar, Arundhati Muralidharan (eds). Springer, 2017. 226pp, price not mentioned. ISBN: 978–981–10–5999–5.

This book is edited by 2 scholar–academicians in public health who attempt to synthesize the efforts in understanding and addressing social determinants of health (SDH) in India through 10 case studies from different parts of the country. The editors hope that this will help policy-making institutions operationalize the sustainable development goal agenda not only in India but also in other low- and middle-income countries.

Social factors, as opposed to biological and individual factors, have now been widely agreed to be far more important than biological or behavioural factors in determining health of communities. While what factors operate through what pathways has engaged people over decades, WHO took note of this formally in 2005 when they set up a commission that came out with a rather comprehensive report in 2008. This book attempts to use experiential grounding to come up with an understanding in the Indian context a decade later.

Aptly, the editors and several contributors discuss the ‘social’ and the ‘determinants’ in the much-abused phrase SDH. Does ‘social’ mean all what is not personal or biological? Social determinants, as the editors point out, include those that people are born with and live with such as those of identity, material circumstances and socioeconomic opportunities and power relations between people. In fact, political decision-making and economic policies and milieu are something which should not be left outside the ambit of social factors. That public institutions and political decision-making has a considerable role in determining health is explained through its introduction to this book. They take us through a journey in time from where the understanding of social determinants began. The editors rightly provoke that by ' social’ we are not talking about something apolitical and beyond the remit of the government. SDH should not hide what society, government and state have failed to do, or be used to shift blame to those aspects that are mired in ‘society’ and are thus beyond government control.

Does the current discourse in India obfuscate SDH by highlighting the more proximal factors while diverting or ignoring the distal critical factors? Are social structures, economic and social policies being addressed in the SDH agenda? For example, how do the pharmaceutical policies both for pricing and for patent granting, use of legal provisions such as compulsory licensing and defending national needs at the World Trade Organization summits determine health? By redefining the SDH agenda, the editors use several case stories to expand our understanding. Thanks for the same.

Health is a deeply political issue. When they use the world palimpsest to describe the changing discourse on sociopolitical discourse in health, the book finally reaffirms the importance of what Rudolph Virchow described 150 years ago as ‘health as a social science, and politics is nothing more than medicine on a large scale … and health workers are the natural attorneys of the poor and social problems largely fall in their jurisdiction’. The National Health Policy 2017 seemed to have relegated SDH to ecological factors such as pollution and individual risk factors such as exercise and diet with hardly any attribution to larger political and economic frames and the way power and policy is distributed. Through the stories of praxis of addressing these social concerns, the editors have rightly tried to make health a political issue, thus undoing a wrong turn in the trajectory of understanding health needs.

A full chapter explores and recommends inclusion of conflict as an important determinant of health. Another discusses the identity of people and health system-related factors in determining maternal health and survival. There are some fine commentaries accompanying these case studies that bring out the politics of health.

Yet, I think that the editors held back some punches and avoided criticizing attempts to depoliticize health. One did not find any substantial discussion of how social identity such as caste determines the ability of communities to be healthy. Issues of very real ‘discrimination’ against Adivasis, Dalits, minorities and women seem to have missed adequate emphasis. As one commentator mentions in an article, cultural hegemony and rampant liberal capitalism in India seem to determine atrocities even in the domain of health and needs to be taken note of.

Another contributing author has rightly exhorted us that we should ask why governments and private sector are not held accountable for their policies and practices and why is there no political will to address the SDH. Why don’t we increase the ambit of determinants to include the impact of economic priorities and policies, tax regulations, corporate practices in determining health, asks another author?

This interest in SDH is an opportunity to generate locally relevant systems framework and methods that can address the upstream macro-determinants and its complexity. It is also a call to take up an expanded concept of SDH to make it truly interdisciplinary.

Several chapters have applied a nuanced lens through which they propose how health determinants can shape health inequalities in India. Some others also suggest ways to assess remedial action on SDH at community, state and national levels by the State and non-governmental organizations (NGOs). Thus, it seems like a rich patchwork of how SDH is understood, acted upon and assessed in India. This experiential learning is being described as a process and not a fully matured product by the editors, which strikes me as being justly modest.

The production is of a high quality with good-sized fonts. Expectedly, the book is mainly textual with few figures and no illustrations. I would recommend this book for policy-makers, health programme coordinators and students of public health and anyone else interested in political economy in health, to become aware of the discourse of why we as a society are not healthy. For those embarking to understand the structural violence that determines the ability of some people to remain healthy, this book would make interesting reading.